Barbara Galuppi

Development and reliability of a system to classify gross motor function in children with cerebral palsy

To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five‐level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (k) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.

Development of the Gross Motor Function Classification System for cerebral palsy

The Gross Motor Function Classification System (GMFCS) for cerebral palsy has been widely used internationally for clinical, research, and administrative purposes. This paper recounts the ideas and work behind the creation of the GMFCS, reports on the lessons learned, and identifies some philosophical challenges inherent in trying to develop an ordered, valid, and consistent system to describe function in children and adolescents with developmental differences. It is hoped that these ideas will be useful to others who choose to expand the field with additional systems in other areas of childhood neurodisability.

Health status of school-aged children with cerebral palsy: information from a population-based sample.

In this study parents’systematic accounts of the health status of 408 school‐aged children with cerebral palsy (CP) are reported (221 males, 187 females; mean age 8 years 5 months, SD 1 year 11 months; range 5 to 13 years), as are relations between severity of functional motor impairment and eight functional health status domains. Data were collected as part of a longitudinal study of the motor development of a population‐based, stratified, random sample of children with CP from across Ontario, Canada. The Gross Motor Function Classification System (GMFCS) was used to classify severity of CP and functional health status was described with the eight‐level Health Utilities Index ‐ Mark 3. Rates of functional limitations in Mobility, Dexterity, Speech, and Vision were statistically significantly associated with GMFCS levels (all p<0.01), with correlation values (tau‐b) of 0.82,0.58,0.46, and 0.36, respectively. Functional limitations in hearing (tau‐b=0.16; p=0.04) and cognition (tau‐b=0.27;p<0.01) were both statistically significantly associated with GMFCS levels, though correlations were low. Neither emotion (tau‐b=0.03;p=0.24) nor pain (tau‐b=0.07;p=0.37) was associated with degree of functional limitation as described by the GMFCS. Clinical and epidemiological implications of findings are discussed.

Reliability of family report for the Gross Motor Function Classification System.

The aim of this study was to determine the reliability of family reports for the Gross Motor Function Classification System (GMFCS), a condition-specific discriminative measure of severity of movement disability for children with cerebral palsy (CP). We conducted a cross-sectional survey using a short questionnaire with families of children with CP for whom we already had ratings of GMFCS level made by a health professional. We assessed the potentially confounding effect of whether the family had discussed the GMFCS with a professional. Two hundred and one questionnaires were posted to families of which 97 (48%) were completed and returned. Mean age of the children (53 males, 40 females) was 9 years 5 months (SD 1 year 1 month), range 6 to 11 years. Children of the families who responded encompassed the spectrum of types and distribution of impairment and severity of movement disability. The intraclass correlation coefficient (ICC) of agreement between professionals and families who had discussed their childs GMFCS level with a health professional (n=35) was 0.97 (95% confidence interval [CI] 0.96 to 0.98); for those who had not (n=52) the ICC was 0.92 (95% CI 0.91 to 0.93); and for the whole sample (n=93) the ICC was 0.94 (95% CI 0.90 to 0.96). Stability between ratings made by health professionals for children when they were in the 4 to 6 year age band of the GMFCS and ratings made by families for the same children when they were in the 6 to 12 year age band (n=35) was ICC=0.96 (95% CI 0.95 to 0.97). The excellent agreement demonstrated in this study suggests that family reports of the GMFCS made by using our questionnaire provide a reliable method for measuring gross motor function in children between 6 and 12 years old. This might be more efficient for observational studies of large populations, experimental research, or community health administration than direct observation, particularly when professional assessment is not feasible.

Quality of life and health-related quality of life of adolescents with cerebral palsy

This study assessed quality of life (QOL) and health‐related quality of life (HRQOL) of 203 adolescents with cerebral palsy (111 males, 92 females; mean age 16y [SD 1y 9mo]). Participants were classified using the Gross Motor Function Classification System (GMFCS), as Level I (n=60), Level II (n=33), Level III (n=28), Level IV (n=50), or Level V (n=32). QOL was assessed by self (66.5%) or by proxy (33.5%) with the Quality of Life Instrument for People With Developmental Disabilities, which asks about the importance and satisfaction associated with the QOL domains of Being, Belonging, and Becoming; HRQOL was captured through proxy reports with the Health Utilities Index, Mark 3 (HUI3), which characterizes health in terms of eight attributes, each having five or six ordered levels of function. GMFCS level was not a source of variation for QOL domain scores but was significantly associated with the eight HRQOL attributes and overall HUI3 utility scores (p<0.05). Some QOL domain scores varied significantly by type of respondent (self vs proxy; p<0.05). Overall HUI3 utility values were significantly but weakly correlated with QOL Instrument scores for Being (r=0.37), Belonging (r=0.17), Becoming (r=0.20), and Overall QOL (r=0.28), and thus explain up to 14% of the variance (r2). These findings suggest that although QOL and HRQOL are somewhat related conceptually, they are different constructs and need to be considered as separate dimensions of the lives of people with functional limitations.

Evaluating motor function in children with Down syndrome: validity of the GMFM.

The Gross Motor Function Measure (GMFM) was developed and validated originally by Russell and colleagues as an evaluative assessment of gross motor function in children with cerebral palsy (CP). The present study reports the results of reliability and validity testing of the GMFM for use with children with Down syndrome (DS). One hundred and twenty‐three children with DS were assessed twice over a 6‐month period, using the GMFM and the motor scale of the Bayley Scales of Infant Development ‐ second edition (BSDD‐II). In addition to the usual method of scoring the GMFM using only observed motor behaviours (standard score), parent reports of childrens activities not seen by the assessor on the day of testing were also obtained and a second score (reported score) was calculated for each GMFM assessment. Test‐retest and interrater reliabilities were excellent (all > 0.90). Observed correlations between change on GMFM and judgements of change made independently by parents, intervenors, and masked video raters were lower than hypothesized. However, the pattern of change scores in predefined age and severity subgroups supported the contention that the GMFM was able to detect differential amounts of change as predicted. The GMFM was shown to be relatively more responsive to change in gross motor function than the motor scale of the BSID‐II. The ‘reported’ scores on the GMFM demonstrated better evidence of reliability, validity, and responsiveness than the standard scoring method and this approach is recommended for use when assessing children with DS.

Correlates of decline in gross motor capacity in adolescents with cerebral palsy in Gross Motor Function Classification System levels III to V: an exploratory study

Aim  To explore associations between clinical variables and decline in motor capacity in adolescents with cerebral palsy (CP).

Using the Gross Motor Function Measure to Evaluate Motor Development in Children with Down Syndrome

The purpose of this article is to describe our clinical experiences in using the Gross Motor Function Measure (GMFM) to evaluate motor development in children with Down syndrome and to provide strategies we found helpful in enhancing a childs adherence to standardized testing. The issues discussed are: (1) strategies for test administration; (2) modifications in administration and scoring; (3) reliability of the GMFM using the modified administration and scoring procedures; and (4) applications of the GMFM for clinical practice. The strategies and recommendations address the particular characteristics of children with Down syndrome and allow for their progress to be monitored relative to other children with Down syndrome rather than to children without motor delays. Future studies validating the use of specific goal areas for the administration and scoring of the GMFM for children with Down syndrome are recommended.

Consensus classifications of gross motor, manual ability, and communication function classification systems between therapists and parents of children with cerebral palsy

SIR–The purpose of this communication is to share our experiences of establishing consensus classifications between trained research service providers and parents of children with cerebral palsy (CP) using the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS). We anticipate that our interim solutions for dealing with situations in which consensus was not achieved might contribute to the establishment of ‘current best practices’ in obtaining consistent consensus classifications internationally. This work is conducted in the context of a multi-site international study on ‘Developmental Trajectories of Impairments, Health Conditions and Participation of Children with Cerebral Palsy’ (short title: On Track Study). In previous work, we established an understanding of the child, family, and service factors that contribute to motor development, self-care, and participation (under review) of two functionally distinct subgroups of children with CP. To assist with planning for individualized care to optimize these outcomes, the next stage in our research is to describe the developmental trajectories (both longitudinal growth and centile curves) of change in balance, limitations of range of motion, strength and endurance, and number and impact of associated health conditions, as well as participation in self-care and recreational activities. We plan to present these trajectories using a combination of the GMFCS, MACS, and CFCS levels. The GMFCS, initially designed for service providers to classify usual motor performance of children with CP, was later validated for completion by parents. Both the MACS and the CFCS were developed for service providers to use in collaboration with parents. Acknowledging the importance of both parent and service provider perspectives in classifying the full range of usual ability across settings, we have developed a consensus approach to classification rather than comparing independent classifications. We have data from the first time point of our longitudinal study from parents of 671 children with CP (56% male) between 2 years and 12 years of age (average 6y 3mo, SD 31mo) enrolled in the On Track Study using convenience sampling from a variety of clinical settings in Canada and the US. Of the respondents, 88% were mothers; 77% had some form of post-secondary education. Ninety trained and reliable physical or occupational therapists provided service provider perspectives. Ethical approval was provided by the Health Sciences Research Ethics Board at Western University and similar ethics boards at McMaster University, Drexel University, and the University of Washington (as well as Mercer University and Oklahoma University of Health Sciences) and multiple agencies across all participating sites (http://www.can child.ca/en/ourresearch/on_track_study.asp). All ethical recommendations have been adhered to. Signed informed consent/assent was obtained from each parent/child participant prior to data collection; all consented to data being used in publications. Parents were asked to complete the GMFCS, MACS, and CFCS prior to a therapist visit. During the visit, parents and therapists discussed the classifications and the therapist documented: (1) immediate agreement with the

Interrelationships of Functional Status and Health Conditions in Children With Cerebral Palsy: A Descriptive Study

Purpose: To examine the relationship among the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS) in children with cerebral palsy (CP) and to determine the average number and effect of health conditions. Methods: Participants were 671 children with CP aged 2 to 12 years from Canada and the United States. Cross-tabulation of functional classifications and averages were computed for the number and impact of health conditions and comparisons among groups. Results: A total of 78 of the 125 possible classification combinations were recorded. Most frequent were GMFCS I, MACS I, CFCS I; GMFCS I, MACS II, CFCS I; and GMFCS II, MACS II, CFCS I. With lower levels of function, the average number and average impact of associated health conditions increased. Conclusions: The use of functional profiles across classification systems, with data on the associated health conditions, provides a more comprehensive picture of CP than any single classification or measure.